Editing Peptic ulcer disease (section)

=== '''Perforation     (9%)''' ===

** 60% are duodenal, 20%      antral, 20% gastric
*** Gastric more likely (10%)       to contain malignancy
*** Most gastric perforations       occur along the anterior aspect of the lesser curvature
** Presentation:
*** Phase 1 (0-2 hours)
**** Sudden onset epigastric        pain, becoming more generalised
**** Local chemical peritonitis        - doesn't want to move
**** Presyncope/syncope, weak        pulse, cool extremities, tachycardia
*** Phase 2 (2-12 hours)
**** Pain may improve, but        generalised, worse with movement
**** Peritonitic, rigid,        tympanitic over liver, ileum
*** Phase 3 (>12 hours)
**** Hypotension, CV collapse
** Investigation
*** CXR - free gas in 65%
*** Typical history and CXR       could technically be enough to operate
*** CT if any doubt, preferably       with oral contrast
** Scores
*** Boey
*** PULP (Peptic ULcer       Perforation score)
** Management:
*** 2x peripheral canulas, NBM       + NGT, IVF, IDC, IV PPI, Abx (cover enteric gram negative rods,       anaerobes, mouth flora - i.e. cef/met or piptaz, add in antifungal if       sick), ?ICU, goals of care
*** Medical
**** 'Herman Taylor regimen'        from a paper in 1946
**** Can sometimes be used in        patients <70yo, well, early presentation
**** Only consider in patients        with localised symptoms, in stable condition, and with a contrast study        confirming a sealed leak
**** Close monitoring, serial        exams, NPO + NGT, Abx and PPI
**** Perc drainage PRN
**** Short-term mortality in        patients who need surgery but are not operative candidates is 30-60%
*** Surgical
**** Indications
***** Required in almost all         patients
***** Delay to surgery         increases mortality
***** Be aware that free gas         without peritonism can sometimes be managed non-operatively
**** '''Technique'''
***** Open
****** Upper          midline laparotomy
****** 0-3cm          perforation/easy: take full-thickness transversely-orientated (so as          not to stricture the lumen) interrupted bites with 3/0 PDS, clipped          on artery forceps but not tied. Fashion a pedicle of omentum and flip          it into the defect, then loosely tie the sutures. Leak test. 5L wash          and drain.
******* If           omentum is flimsy, can use mobilised falciform ligament or serosal           patch
******* This           is termed a pedicled (Cellan-Jones) or free (Graham) patch
*******
****** >3cm          perforation/difficult/unable to close with simple omentopexy: '''Choose          between definitive procedure or damage control.'''
******* '''Definitive procedure:''' Likely to be           '''resection +/- diversion'''.
******** Distal            gastrectomy and a Bilroth II or Roux-en-Y reconstruction. '''See            separate topic - 'distal gastrectomy'.'''
******** Greater            curvature - easier to wedge resect back to healthy stomach, may not            need to divert
******** A            large lesser curvature or duodenal ulcer is notoriously difficult -            likely to be distal/subtotal gastrectomy.
******** Repair            and diversion, instead of resection and diversion (I think this is            a suboptimal option) - can form a Roux-en-Y bypass/Bilroth II and            then either staple across the distal stomach with a non-cutting TA            stapler, or tie a 1 PDS suture around the stomach to divert, which            will be expected to eventually give way. Another option is to make            a gastrotomy and then place a mucosal purse-string suture around            the pylorus from internally.
******* '''Damage control:''' If unable to perform a definitive           procedure for patient factors or disease factors, will need to do a           damage-control procedure - drain with Foley catheter, washout,           transfer to UGIS unit. Better to do this than try a complicated           resection and reconstruction on an unwell patient with limited UGIS           experience.
******** Tube            duodenostomy - 16Fr Foley surrounded by a loose purse-string to            support it, with additional peritoneal drainage and NGT
******** Bring            some omentum up to cover the defect too
******** '''Triple-ostomy approach''' sits between damage            control and definitive repair - drainage of the ulcer bed (maybe            with a T-tube or IDC), stomach drainage through a PEG/NGT, and            feeding jejunostomy, ideally with pyloric exclusion to prevent            gastric contents contacting ulcer. If doing this, perhaps better            just formally resecting.
***** Laparoscopic
****** Less          morbidity and wound complications
****** Good          option in stable and well-resuscitated patients with an          easily-accessible perforation
***** Lavage with 5-10L N/S
***** Classically, leave a         drain and NGT for two days then restart PO intake after 48 hours.         Consider CT with PO contrast or methylene blue leak test prior.
***** Empiric antibiotics 3-5         days and H. pylori eradication once tolerating oral intake (may need         longer courses of antibiotics with delayed intervention)
*** Endoscopic therapy is       emerging
** Prognosis
*** 30% 90-day mortality
** Special situations
*** Perforation and bleeding
**** Might be a 'kissing' ulcer        - can enlarge the perforation, suture-transfix the bleeding ulcer, then        close the perforation